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Interesting Case Presentation

PI• A 85 y/o woman presented to ED of Rasul hosp.

by EMS with chief complaint of chest pain & generalized abdominal pain since a day before.

• She complained also of nausea & vomitting• Chest pain was dull in Lt hemi-thorax, not

sharp, not squeezing, non radiating• Abdominal pain was generalized, dull, non-

crampy, has had bowel movement, one episode of vomiting mentioned

Ph. Ex• Was oriented, GCS=15/15• Appearance: ill, not toxic• PR=70/min BP=165/75 ( RR=16/min Spo2=90% • Head & Neck: pale conjunctive, JVP, no mass• Chest: clear lungs, no rale irregular heart beats, no murmur,• Abd: Soft, generalized tenderness, no distention, no

rebound• Extrem: No edema, no cyanosis, normal irregular pulses,

force: 5/5

• PMH: HTN, IHD, CKD, COPD (hospitalized for COPD exacerbation 6 months ago)

• DH:AmlodipineNitrocontinLosartanTriamterene-hDigoxinAtorvastatinASA

Problem list

• An old woman presented to the ED by EMS with:

Lt hemi-thorax dull painGeneralized abdominal painNausea- vomitingIrregular pulses since a day before

How to approach this patient

ED work-up• EKG• Lab test, including BS, Troponin, Amylase, ABG, Bil• CXR (upright)• Abd X-ray (upright, supine)• Bedside US(Aort diametr,heart)• Abd/Peivic US (including IVC)• Internal med consult• Surgery consult• Digoxin level• IV fluid N/S 500 ml IV stat• Cardiac monitoring,POM

Lab• WBC=7700 (PMN: 74%)• Hb= 11.4• MCV= 85• PLT= 219000• Troponin: --• K= 5.8 Na= 134• BUN= 59 Cr= 3.12• CPK= 100• Alk-Ph= 103 AST=11 ALT=22• Bil T= 1.46 Bil D= 0.32• Amylase= 89• Ca=8.86• ABG: pH=7.40 HCO3= 10.6 CO2= 17• PT= 14 PTT= 35 INR= 1.1

Abd US

Bedside US

• No pericardial effusion• No free abdomino pelvic fluid• Abd aortic diameter: normal• EF= 55%

Int. Med. consult

• Full ACS order(heparin)• Cardiac monitoring, POM• Surgery consult• Cardiology consult for echocardiography• Check serum level of: Mg, Digoxin• Hyperkalemia management:

Glucose 50% 2 vial IV stat8 unit Regular InsulineKayexalate 30 gr in 100cc tap water PO statSorbitol 30 gr in 100cc tap water PO statFurosemide 40 mg IV stat

Surgery consult

• Abd/pelvic US• Lab test• IV fluid• TR : No significant findings• Mesenteric ischemia R/O(Abdominal us)• Foley cateter fixed• NG tube fixed

Digoxin Level

Serum Dig level > 5

ED

• Internal consult reorder• Post CCU admission

Abd US:

• Sludge in gallbladder• Multiple kidney cysts• No other findings

Echocardiography

Digoxin is absorbed rapidly from the GI tract with a bioavailability of between

75% and 95%, depending on the formulationElimination is primarily through renal excretion, with a half-life of 36 to 48hours in patients with normal renal function and 3.5 to 5 days in

anuricpatients.,with a half-life of 5 to 7 days in adults and up to 12 to 37 daysin individuals older than 80 years old. .2 Inhibition of the sodium-potassium ATPase pump leadsto increased concentrations of intracellular sodium, which subsequentlyincreases sodium-calcium exchange.

CLINICAL FEATURES

• Nausea and vomiting• Headache, dizziness, confusion, coma• Bradyarrhythmias or supraventricular tachyarrhythmias• with atrioventricular block• Hyperkalemia• Marked elevation (if obtained within 6 h)• Typically in elderly cardiac patients taking diuretics;may have renal insufficiencyNausea, vomiting, diarrhea, abdominal pai nFatigue, weakness, confusion, delirium/ comaAlmost any ventricular or supraventricular dysrhythmiacan occur; ventricular dysrhythmias are commonElectrolyte abnormalities Normal or decreased serum potassium, hypomagnesemia

DIAGNOSIS

• The diagnosis of digoxin toxicity is a composite picture, using history,• physical examination, and laboratory studies as pieces of information;• no single element excludes or confirms the diagnosis. In patients with• heart failure and normal renal function, daily digoxin doses are

usually• between 125 and 250 micrograms. Digoxin toxicity can occur with a

single• ingestion of 1 to 2 milligrams in an adult, and fatalities have been

reported• following an acute ingestion of 10 milligrams in an adult and 4• milligrams in a child.

ECG

• Four specific electrocardiographic findings have been described with• therapeutic levels of digoxin and are not signs of

toxicity. These findings• include T -wave changes such as flattening or

inversion, QT -interval• shortening, a "scooped" appearance of the ST -

segment with ST -segment• depression, and an increase in U-wave amplitude

LABORATORY EVALUATION

• In acute poisonings, the serum potassium and digoxin levels can provide useful diagnostic information

• The serum potassium level may be a better indicator of end-organ toxicity and a better prognostic indicatthe acutelyor than the serum digoxin level in oned patientpois.

• . Accepted therapeutic digoxin levels are 0.5 to 2.0 nanograms

TREATMENT

• General supportive care• Treatment of specific complications of toxicity, prevention of furtherdrug absorption, enhancement of drug elimination, antidote administraI• Treatment of Digitalis Glycoside PoisoningAsymptomatic patients:• Obtain accurate history• Continuous cardiac monitoring• IV access• Gl decontamination: activated charcoal, 1 gram/kg PO• Frequent reevaluation• Calculate digoxin-specific Fab antibody fragments dose in anticipation ofpotential need: may bring to drug bedside, depending on ready availabilitySymptomatic patient:• Obtain accurate history• IV access

• Continuous cardiac monitoring• Gl decontamination : activated charcoal, 1 gram/kg PO, then 0.5

gram/kg every• 4-6 hBradyarrhythmias:• Atropine: 0.5-2.0 mg/ IV• Pacemaker: external or transvenous• Digoxin-specific Fab a ntibody fragments: IV infusionVentricular dysrhythmias:• Digoxin-specific Fab a ntibody fragments: IV infusion or bolus• Magnesium sulfate: 2-4 grams IV• Lidocaine: 1 mg/kg• Fosphenytoin: 15 mg/kg, infuse at 150 mg/minute• Electroca rdioversion: 10-25 J (last resort)

Cardiac arrest:• CPR with current ACLS protocols• Digoxin-specific Fab a ntibody fragments: IV

bolus (5- 10 vials if amount ingested is unknown)

Hyperkalemia:• Avoid calcium chloride or calcium gluconate*• Glucose-insulin

• Sodium bicarbonate• Digoxin-specific Fab a ntibody fragments: IV i

nfusion or bolus• Potassium resin binder• HemodialysisHypomagnesemia:• Evaluate renal status prior to replacement• Magnesium sulfate: 2-4 grams IV

Gl DECONTAMINATION AND ENHANCED ELIMINATION

• Administrating activated charcoal may have utility in early acute ingestion of digoxin

• Gastric lavage is not recommended, as asystole has been reported

in a digoxin-toxic patient, presumably from vagal stimulation during lavage• Cathartics, forced diuresis, hemodialysis, or hemoperfusion

have no role in enhancing elimination of digitalis glycosides

DIGOXIN-SPECIFIC Fab ANTIBODY FRAGMENTS

Patients developing cardiac arrest before digoxin-specific Fab antibodyfragment administration had a 50% survival, which is significantly better than historical survival by treatment with conventional therapies

. Indications for digoxin-specific Fab• Ventricular dysrhythmias• Bradyarrhythmias unresponsive to standard

therapy• Hyperkalemia in excess of 5.5 mEq/L associated

with a toxic digoxin level • Based on serum digoxin concentration: total-

body load = [serum digoxin level (nanograms/ml) x 5.6 L/kg x patient's weight (kg)]/1000

• Number of vials = [serum digoxin level (nanograms/ml) x patient's weight

• (kg)]/100• Fab antibody fragment administration is adverse• has been reported in patients dependent Cardiogenic shock on digoxin for inotropic support., ventricular response to• Hypokalemia • atrial fibrillation may be increased. serum sickness or

anaphylaxis have been observed, even in.

DISPOSITION AND FOLLOW-UP

• Because toxicity may not develop for several hours, extended observation up to 12 hours is recommended for anyone with a confirmed ingestion

• Patients with signs of toxicity or a history of a large ingested dose

should be admitted to a monitored unit.• Consultation with a medical toxicologist or the

regional poison control center can facilitate difficultmanagement and treatment decisions

• Any patient receiving digoxin-specific Fab antibody fragments requires intensive care unit observation for at least 6 to 12 hours.

• suicidal patients should have a behavioral health or psychiatric evaluation before discharge.

• Accidental exposures with no signs of toxicity after• 1 2 hours can be discharged home.